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A 72-year-old woman presented to the emergency department with intense crushing central chest pain for 3 days, not radiating to arms/jaw, and not associated with exercise. She had no fever. Troponin I was elevated at 3.57 ng/l on admission, and reached a peak value 3.88 ng/ml (normal range <0.09 ng/l). Creatinine phosphokinase concentration was 155 U/I (normal range <170 U/l) and the C-reactive protein level was 46 mg/l (normal range <5 mg/l). A 12-lead electrocardiogram (ECG) on admission showed normal sinus rhythm with a heart rate of 94 bpm and ST abnormalities with a negative T wave in the inferior leads and V5–V6 (fig. 1). Transthoracic echocardiography revealed mild hypokinesia of the basal and mid-cavity lateral wall, with a normal overall ejection fraction (EF) of 60%, and no pericardial effusion. In view of the acute coronary syndrome and regional wall motion abnormalities, the patient underwent invasive angiography, which showed unobstructed coronary arteries (fig. 2 A,B,C). She was then discharged with a diagnosis of acute myo carditis and referred for CMR for confirmation of the diagnosis. CMR was performed on a 3T system (Skyra, Siemens Medical Solutions, Erlangen, Germany). The cine CMR images confirmed the persistence of regional wall motion abnormalities in the lateral wall and global EF of 56% (fig. 3 A,B). Advanced myocardial tissue characterisation with T1 and T2 mapping confirmed the abnormal value myocardial signal intensity (T2 mapping: 60 ms, normal range in our lab <45 ms; T1 mapping: 1600 ms, normal range for our lab is <1200 ms) suggesting myocardial oedema in the region of wall motion abnormality (fig. 4 A,B) Late gadolinium enhancement (LGE) images acquired after administration of a contrast agent revealed transmural LGE of the left ventricular mid-anterolatSummary

The diagnostic dilemma of myocardial infarction with unobstructed coronary arteries